Presentation of Lung Cancer (applies to all cancers)
a) Signs& symptoms of primary tumor
b) Signs & symptoms of secondary spread
c) Other things
Is patient hoarse, coughing up blood.
Examine neck & abdomen for lymph nodes.
Spead to bone - bone pain & fracture
SOB if spread throughout lung
Brain => personality change
Weight loss, raised ESR, raised Ca, raised temperature, polycythemia
Treatment of Tumors
If inoperable, say "Tender Loving care" - ie. Palliative
Surgery - only 10% are sugerically appropriate
Chemo
Radiotheraphy
Hormone (for breast Ca)
Immunotheraphy (for melanoma)
Never be rude to patient or hurt patient. Treat patient as if they were your own mother.
To access if fit for surgery: Ask if patient can walk up stairs.
If thin with big neck => SVC obstruction (Rx = Radiotheraphy & Stenting)
Practice saying "Neoplasm" before exam, as patient may not yet know they have cancer.
If pain => nerve block.
If SOB => Tap fluid. May add talc or belomycin to prevent collapse.
Long case - Persistent diarrohea
If young but not acutely ill => UC, Crohns, polyposis coli, or carcinoma, (or diverticuli)
Presentation: If patient acutely il - may need urgent operation
Chronic ill health
Take Hx: ask if up at night with diarrohea (means it is severe)
Any blood passed, Any weight loss.
Investigations:
Recognise iron deficiency on blood form
ESR, CRP => Inflammation
U+E
Unless contra-indication (eg. Toxic megacolon or perferation) do barium enema.
X-Ray => Rose thorn ulcers, skip lesions => Crohn’s
Indications for surgery
a) Emergency: If massive haemorrhage, perforation, toxic meacolon
b) In 4 or 5 days: If failure to respond to medical theraphy
c) Elective: Chronic ill health or Cancer.
Stomas:
Colonstomy: Flat mouth
Iliostomy: has a spout (as small bowel fluid irritates skin), contains fecal material.
Urostomy: contains urine
Fistula: for drainage
BUT don’t assume it is an iliostomy because it is on the right.
Neck Lumps
Is patient’s breathing compromised?
How long has mass been there?
Carotid body tumor
Thyroid
If patient is in a chair (rather than a bed), then must be Thyroid, Jupetrons contracture or Rheumatoid. If glass of water, then thyroid.
What age, sex, fat/thin, cigarette stains (may be lymph node from lung neoplasm)
If young girl, probably brachial cyst.
When examining neck, think about the layers of tissues around neck:
Skin
- Basal cell carcinoma in older patient, face exposed to sun, Has raised rolled edge, tiny blood vessels (telangtasia).
- Sebacious cyst - black pundtium in center
- Squamous cell cancer - ragged ulcer, sun exposed
- (Keratoma - a benign viral thing)
** Then examine lymph nodes in neck **
Fat - Benigh lipoma - soft, can move skin, usually back of neck, only remove if bothersome.
Nerve - Benign neuroma - will be slightly painful when palpated.
- Has the patient got many => Von Nechen housins disease
- If deaf => Acoustic neuroma
Lymph node - if older smoker (usually looks unwell) => secondary spread of cancer
If young (may look well) => Lymphoma
Benign - TB, scardoidosis, toxoplasmosis => look for skin lesions
If feels hard
If lymph node, say "I’d like to examine further" including:
a) Draining area of that node (inside mouth)
b) Other lymph nodes (groin, axilla)
c) Spleen & liver
Look inside mouth (use torch, look under tongue & inside both cheeks): - If white plaque, then:
Leucoplachia = raised white areas.
Lichen planus = looks like lacework - benign, so NOT on ward
Squamous cell = bleeding raised white area
Tests:
Blood - WCC for leukaemia
ESR, CRP
LFT’s - for liver mets
CXR
ENT consult - for larynx
Fine needle biopsy is KEY test - can diagnose secondary cancer, and benign things, but can’t diagnose lymphoma.
Brachial cysts - pain as sterno-mastoid, soft & fluctulant
- ultrasound & fine needle biopsy - for cholesterol crystals
If swelling below mandable - if swells & sore when eating, then stone in duct from submandibular gland.
Look for symmetry & facial nerve palsy
Any lump in front of ear - lymph node in parotid gland maybe TB, lymphoma, or parotid tumor (NOT abcess as it is very painful)
If facial nerve working?
Tumors can be: (a) Benign - pleomorphic adenoma (middle aged female, facial nerve okay), Warfarins (older man, soft, cystic, maybe bilateral)
(b) Malignant - Adenocarcimoma (facial nerve gone - ask if can show teeth)
-Acinic cell tumor (PAINFUL as infiltrates into trigeminal nerve)
(c) In between - Meuco-epidermoid tumor
Rx: Surgery or Chemo.
Thyroid
Age, Sex, Thyroid status (big exopthalmus eyes, thin, young female, sweaty hands, or middle aged, dry hair)
Thyroid eye signs - lid retraction, lid lag, exopthalmus
Thyroid status - offer glass of water,
- Diffusely swollen or solidary lump in gland? -(i) a benign colloid cyst
-(ii) Tumor: Follicular, medullary, aniplastic
If female think benign, if male think cancer.
(i) Aniplastic - Old lady, hard solid mass - fine needle biopsy, No curative treatment.
(ii) Medullar cell tumor - Thyroid lump. Has patient family Hx of thyroid cancer or other endocrine tumors? Or patient had previous tumor?
(iii) Follicular - FNB not helpful, spreads by blood to lung & bone
(iv) Papillary cancer - Total thyroidectomy. Put patient onto Thyroxine before surgery to suppress TSH.
Carotid body tumor (rarer):
Rule of 10’s: 10% malignant, 10% bilateral, 10% famialial
(Never say "Parathyroid lump". You’ll never see laryngeal lumps)
If old frail lady - paraphyengeal pouch - on X-ray can see pouch. Hx of difficulty swallowing, smelly breath, regurgitates old smelly food after meals
If trachea pushed to one side - thyroid lump?
Scull X-ray - Very dense => Paget’s disease. Alk phos is raised (if in thousands, then osteosarcoma, a cimplication of Pagets), Ca is normal.
What does "taphybasia" mean? => base of scull thickens down to vertebra => compresses cranial nerves as exits there)
Xray of old lady - showing swab left from surgery 5 years ago -> Abcess & fistula formation.
Hand X-ray
Swelling
Erosions of proximal phalynx -> Parathyroid disease - Ca will be high too. But multiple bone secondaries cause raised Ca.
Know common sources of bone mets.
Pelvic X-ray:
Missed CVH
Breast
("Triple assessment" is buzz word)
Female with lump - usually discrete lump.
Don’t diagnose a benign fibroadenoma if white-haired girl.
Assume breast cancer until proven otherwise.
Treat patient kindly as probably just told.
Examine the other breast.
Superclavicular fossae + Axilla!!!
Ask to examine abdomen for asities & liver
Ask to raise arms behind head, and then to press on hips.
Cover the patient again, before presenting.
Say "This lady .. can feel lymph nodes"
Ix: Say in this order (as needle biopsy cause haematoma which looks like tumor):
- Mammogram
- U/sound
- Needle biopsy - in OPD takes 15 minutes till result, no anaesthetic, just syringe & blue needle. (Whereas, core biopsy - done if needle biopsy is unclear, needs anaesthetic, 48 hours till result)
Rx:
Surgery - Partial masectomy (=lump + 1cm around)
- Simple (ie. Total) macectomy = skin + fat & breast, but not pecs muscles
- (+ Radiotheraphy, otherwise 30% reoccur)
- + Lymph nodes - sample 4 axillary nodes OR "Sentinal node biopsy" = a blue dye with radio marker is squirted into cancer area, then wait 15 minutes, then identify node which collects it - ie. the sentinal node which is biopsied in detail to determine if spread beyond this node)
- Then axillary glands are mostly removed.
Breast reconstruction
- can do at masectomy or later
- By: a) Implant
- b) L-D (latimus-dorsi) flap
- c) Tran-flap = rectus muscle & fat of abdomen moved up to form new breast.
Breast implants do NOT cause cancer.
If only one met in lung or brain - can remove, BUT liver nearly always has more, so chemo only then.
If bony secondaries - very painful - use Radiotheraphy
Chemo - often given routinely to younger patient (<50years)
Know a bit about Temoxaphen -> big help to oestrogen receptor positive breast cancer, given for 5 years to over 50’s. BUT risk of endometrial cancer (bleeds)
Temoxofen reduces cancer risk in other breast, or if high family Hx risk. But UK say risk of endometrial cancer & DVT is too high, but Americans give it.
Screening
Women 50 to 64, every 3 years mammogram, patient not examined
10% look odd - recalled for further biopsy
Now started screening 50 to 70 years in UK.
Under 50’s mammogram is hard to read, as firm dense breast appears all white.
Survival in NI:
78% 5 year survival, which is good for UK.
Whereas: lung cancer: 9%
Oesophagus 11% 5 year survival
Jaundice from head of pancreas - 0% 5 year survival.
Guidewire is often used to identify breast cancer under radiology, for surgery later.
Diverticular disease:
Complications: Bleeding, perforation, Abcess, Peritonitis, Stricture.
but does NOT become cancer.
Hammartoma = benign round lung lump in X-ray (although looks like cannon-ball mets)
Oesophageal cancer:
Dysphagia - reflux stricture (patient looks well) = rat’s tail stricture
Cancer - thin wasted smoker - feel for liver, CXR, U/sound abdomen for liver, barium swallow, endoscopy, endoluminal ultrasound
Hylar mass - if bilateral -> lymphoma, sarcoid
- unilateral -> lung cancer, ragged edge
- if smooth edge - dissecting aortic anyerism
Bowel cancer - Long case
Middle aged, or older
Change in bowel habit
Passing blood per rectum
Iron deficient anaemia for no other cause => Cancer of ceacum or cancer on Right Colon => ulcer which bleeds => Anaemia
Left colon => Stricture => crampy pain, vomiting
Rectum => Ulcers => Bleeds
Look for Jaundice in eyes
Offer to do rectal examination
If cancer in Right colon => Right hemi-colectomy
If cancer in Sigmoid => Sigmoid colectomy
If cancer in Rectum => If low - remove rectum & permanent colostomy, If higher - anterior resection (& can reconnect later)
Radio-therapy only for Rectum - to shrink large tumor, or if some tumor left after op.
Dukes A=mucosa only - no chemo
Dukes B = only in walls - chemo trials
Dukes D = to lymph nodes - chemo
If liver secondaries - if less than 4 can remove
- if had endocrine tumor then can transplant liver
- chemo if patient fit enough
- embolisation of tumor blood supply
- Japanese are injection per cutaneously into mets with 100% alcohol.
Small bowel obstruction
Causes - Adhesions, secondary cancer (esp. ovarian), abcess, Crohns, Tumors (are mostly secondaries & benign playlomas <- wrong spelling!)
Some common X-rays
Raised Right hemi-diaphragm usually means bowel perforation, (but may be a subphrenic abcess or collapsed lung, which can look similar)
Hand X-Ray - parathyroid disease
Submandibular stones on X-Ray.
Rats tail barium swallow - cancer of oesophagus
Crohns = deep fissures, rose thorn ulcers
ERCP = whits tube on X-ray
Jaundice Long case
-Look at patient
Mostly obstructive jaundice = Gall stones in common bile duct = female, middle aged, fat
OR Cancer of head of pancreas = old man, thin, green.
Pale stool, dark urine, lost weight
Look at eyes for anaemia
Lymph nodes in neck
Liver lumps = mets, backpressure
Covasias law = if can palpate gall bladder in presence of jaundice, then is cancer of head of pancreas.
"What do you think clinical problem is?"
What tests?
Haemoglobin - for anaemia - as loosing blood from head of pancreas.
Or haemolytic anaemia = as pigment stones into bile duct => spleen would be palpable. And Reticulocyte count normal =0.5% (whereas upto 10% if haemolytic)
WCC
LFTs
Bilirubin
Raised Alk Phos (gamma GT up slightly)
Coag screen - as Vitamin K dependant factors 2,7,9,10 <- *KNOW these numbers*
Ultrasound for: Dilation of bile ducts, stones, liver secondaries, tumor of pancreas, ascites, big sleen.
Ultrasound guided needle biopsy (coag screen beforehand!)
Usually bile duct dilation as obstruction, but not dilated if: sclerosing cholangitis, liver chirrosis, or liver full of secondaries (as ducts cannot dilate then)
CT scan
ERCP - diagnostic for stone/tumor biopsy, AND can pull stone down or stent.
MRC (MRI with IV contrast of gall bladder & ducts) - good picture of ducts.
If develops abdomen pain - measure Amalyse - as 10% get complications of ERCP.
If reduced urine output (normal output=??) - if only 30ml/hr => dehydrated, but try to rehydrate
Short case X-rays:
X-ray - ragged cancer of oesophagus
Smmoth narrowing of oesophagus = extrinsic pressure
Polys in colon
Trachea deviated
Kidney stones
IVP - can look like stage-horn calculi
Pharyngeal pouch
Groin
Can I get above the swelling?
Inguinal
Hydrocoels - as testis is swollen
Epydydamial cyst
Varocoel (left side)
Don’t diagnose a testicular cancer - as squeezing out cells by many students palpating would be bad practice.
U/sound scan
Short case X-rays:
CT - of liver & Ascities in female = cancer of ovary
X-ray - massive atrial swelling
MRI has a hazy sheen - can see stones
Black lines on CXR - eg. perforated ulcer = a little air under diaphragm
Perforated bowel = big air under diaphragm
Small bowel obstruction X-ray
Thoricoplasty = lung collapsed for TB in past.
Bamboo spine = Ank sponk
Severe constipation = very bubbly pelvic X-ray.